Healthcare Provider Details

I. General information

NPI: 1811168172
Provider Name (Legal Business Name): JILL LORI BASSO MA BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 MEDIO ST.
SANTA FE NM
87501
US

IV. Provider business mailing address

1705 MEDIO ST.
SANTA FE NM
87501
US

V. Phone/Fax

Practice location:
  • Phone: 505-986-6114
  • Fax:
Mailing address:
  • Phone: 505-986-6114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCERT#1-03-1109 BCBA
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6162
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-03-1109
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: